Frameworks for Internal Medicine
In the end, after the “large group learning studios” have fallen silent, the “breakout” rooms are in disarray, and nobody knows that the remotes for the massive TV sets no longer work, medical students will still know 90% of the expected core knowledge. How can this be? It is because these handpicked students are surrounded by handpicked residents, fellows, and junior faculty, all of whom believe it is a fundamental obligation of the profession to teach. They teach all who thirst and most of those who should thirst. It has been this way since the “breakthrough” at Kos. More amazing, the best of these people do not expect any remuneration other than the satisfaction of doing the job well. Education is still the first of the professional expectations at most academic medical centers. These teachers bring the stringent and austere life of physicians-in-training to the task. They can be counted on to teach students what they need to know and, sometimes, what they ought to know.
This task, for which most academic centers pay nothing, is in peril. RVUs, EMRs, “rooming efficiency,” and grading scales for “patient satisfaction” all take a toll. These faculty members are expected to recognize “kaizen events” and alert the managers. Some of the managers want to teach the “silver spoon” doctors a lesson or 2 about “hard times.” Controversy abides, but the teachers persevere. They are, however, in dire need of help.
Where to start? More than anything else, they need blackboards. Blackboards have disappeared. The boards that fill the old blackboard gaps are white and can be written on only with special order pens. When the pens disappear, “informative flyers” begin to fill the space on the whiteboards. “Quiet please. No one can get well in a noisy place!” Are you sure? Sit and listen to an intensive care unit for an hour. “Wash your hands!” The sinks have all disappeared, too, and the wall “hand wash stations” deliver a foul-smelling liquid that fails to dispatch C-diff spores. It has been labeled toxic for human beings by the FDA. Other messages of importance are an invitation to a potluck lunch. There is an invitation to attend the next art committee meeting. The boards are covered with ephemerata. Doctors need a sacrosanct clean board in every corridor of every ward service in every specialty. What will happen at these boards, should they appear, is an ongoing unscripted discussion of the clinical problems at hand for all to see and hear. Approaches to all of the “slings and arrows that life is heir to” show up on these boards. These challenges to health and happiness are ever-present and countless in number. More appear every day. Doctors learn much of what they know at these vestigial boards. Give them real boards and get out of the way! This book preserves the art of Socratic teaching, a method that reaches back 2500 years. Not only does the process reveal what is known but, even more clearly, it reveals what is not known. Everybody learns. Students, teachers, and nurses learn. Laboratory personnel and patients learn. All will evolve and grow. It is a powerful thing to witness.
Fifty of the most common clinical problems are illustrated in this book. The cache of questions will evolve as the anatomy of erudition points the way. This book contains frameworks that guide the discussion of the “chosen fifty.” The 60-year-old man with hematocrit of 32. The 29-year-old pregnant woman with pitting edema to the axillae. The acutely dyspneic long haul truck driver. The young person with fever of unknown origin. The framework prepares the teacher and the learners. It creates the environment most conducive to highimpact learning efficiency. In the end, it is the process rather than the framework. The process becomes generalized. Academia is back on track. Now that we have the book, the boards will appear, hopefully!
Lynn Loriaux, MD, PhD
Professor of Medicine
Oregon Health & Science University
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